Hypertension - Long Case Study With Questions & Answers

Chief Complains:
- Occasional headache, dizziness and giddiness for … months
- Chest pain for … months
- Sleeplessness for … months.

History of presenting Complains: According to the patient’s statement, he was reasonably alright … months back. Since then, he has been suffering from occasional headache, dizziness and giddiness. The headache mostly involves the occipital region and the back of the neck. It is pulsatile in nature, localized, mostly during the daytime, initiated by exertion or anxiety and relieved by sleeping. His headache is not associated with vertigo, nausea, vomiting, visual or hearing problem or facial pain. It is not preceded by any premonitoring symptoms.
He also experiences occasional chest pain on moderate to severe exertion which is relieved by taking rest. There is no cough or breathlessness.
For the last … months, he is experiencing sleeplessness and used to take sleeping pills.
There is no history of fever, loss of consciousness, weight gain, muscular weakness, etc. His bowel and bladder habits are normal.

Family History: His father has a history of hypertension and his grandmother died due to stroke.

General Physical Examination: The patient appears anxious. There is no anemia, cyanosis, jaundice, clubbing, edema, koilonychia, leukonychia, lymphadenopathy or thyromegaly

Vitals;
Pulse: 84/min
Blood pressure: 195/100 mm Hg
Respiratory rate: 18/min
Temperature: 98°F.

The systemic examination was normal.

What is the cause of hypertension in this patient?
This is most likely to be primary hypertension because there are no history or physical signs suggestive of a secondary cause.

What investigations would you do in this patient?
As follows:
1. Routine:
- Urine R/M/E: to see protein, RBC cast, pus cell, etc.
- Blood urea, creatinine
- Serum electrolytes
- Fasting blood sugar
- Serum lipid profile (total serum cholesterol, VLDL, LDL, HDL, triglyceride)
-X-ray chest PA view
- ECG
- Echocardiogram.
2. Other investigation according to suspicion of cause:
- If renal cause: ultrasonogram of whole abdomen, IVU, CT scan of renal system, isotope renogram.
- Cushing syndrome: serum cortisol level, 24 hour urinary cortisol, ACTH, dexamethasone suppression test, etc.
-Pheochromocytoma: 24 hours urinary VMA, serum catecholamines
- Conn’s syndrome: plasma aldosterone and renin
- Coarctation of aorta: CT scan, aortogram



What is hypertensive emergency and hypertensive urgency?

Hypertensive emergency or hypertensive crisis: It means severe elevation of BP (>180/120 mm Hg) with evidence of impending or progressive target organ dysfunction.
It includes hypertensive encephalopathy (headache, irritability, confusion, altered mental status due to cerebrovascular spasm),  hypertensive nephropathy (hematuria, proteinuria, progressive kidney dysfunction due to arteriolar necrosis and intimal hyperplasia of the interlobular arteries),  intracranial hemorrhage, aortic dissection, pre-eclampsia, eclampsia, pulmonary edema, unstable angina or myocardial infarction.
It needs substantial reduction of BP within 1 hour to avoid the risk of serious morbidity or death. Parenteral therapy is indicated in most hypertensive emergencies, especially if encephalopathy is present. At first BP should be reduced no more than 25% within minutes to 1 to 2 hours and then it should be gradually lowered to a target level of 160/100 mm Hg within 2 to 6 hours. Excessive reductions in pressure may precipitate coronary, cerebral or renal ischemia.

Hypertensive urgency means severe elevation in BP without life-threatening target organ dysfunction. It is characterized by asymptomatic severe hypertension (systolic BP > 220 mm Hg or diastolic BP > 125 mm Hg), optic disk edema, progressive target organ complications and severe perioperative hypertension. Here BP must be reduced within a few hours. Parenteral drug therapy is not usually required and slow reduction of BP with relief of symptoms is the goal.

What are the causes of hypertension?
As follows:
1. Primary or essential hypertension (95%).

2. Secondary (5%):

 Renal (commonest secondary cause):
• Chronic glomerulonephritis
• Chronic pyelonephritis
• Diabetic nephropathy
• Adult polycystic kidney disease
• Renal artery stenosis.

 Endocrine:
• Cushing’s syndrome
• Conn’s syndrome (primary aldosteronism)
• Pheochromocytoma
• Congenital adrenal hyperplasia
• Hyperparathyroidism
• Primary hypothyroidism
• Hyperthyroidism
• Acromegaly.

Drugs:
• Alcohol
• Oral contraceptive pill
• Steroids
• NSAIDs
• Erythropoietin
• Sympathomimetics.

Others:
• Pre-eclamptia and eclampsia (toxemia of pregnancy)
• Pregnancy induced hypertension: usually hypertension develops in the second half of pregnancy, which usually resolves after delivery (In contrast, hypertension developing in the first half of pregnancy or persisting after delivery is more likely to be essential hypertension)
• Coarctation of aorta
• Cerebral tumor.

What are the complications of hypertension?
As follows:
1. Cardiovascular:
- Ischemic heart disease
- Acute left ventricular failure
- Dissecting aneurysm.
2. Renal:
- Renal failure.
3. Ocular:
- Retinopathy.
4. Neurological:
- CVD (intracerebral hemorrhage, sometimes infarction)
- Subarachnoid hemorrhage
- Hypertensive encephalopathy.

What is malignant hypertension?
It is characterized by severe hypertension with diastolic BP > 130 mm Hg, associated with grade
III or IV retinopathy (retinal hemorrhage or exudates and papilledema) and renal failure or
encephalopathy. It is a rare complication of hypertension. There is accelerated microvascular damage
with fibrinoid necrosis in the walls of small arteries and arterioles and intravascular thrombosis. This
may lead to LVF and if untreated, death occurs within months.

Treatment: Slow, controlled reduction of BP over a period of 24 to 48 hours is ideal (Rapid reduction
is avoided, as it reduces tissue perfusion and can cause cerebral damage including occipital blindness,
may even precipitate coronary or renal insufficiency).
- Complete rest.
- Oral antihypertensive is sufficient to control the blood pressure.
- Sometimes IV or IM labetalol, IV glycerin trinitrate, IM hydralazine, IV nitroprusside may be given with careful supervision.

What are the grades of hypertensive retinopathy?
Four grades (Keith-Wagener-Barker classification):

• Grade I: Thickening of arterial wall, increase tortuosity, narrowing of arteriole and increased light reflex (silver wiring).
• Grade II: Grade I plus AV nipping and reduction of arterial calibre in comparison to vein (normal ratio of V:A = 3:2).
• Grade III: Grade II plus cotton wool exudate and flame-shaped hemorrhage.
• Grade IV: Grade III plus papilloedema (Grade III and IV indicate malignant hypertension).

What history would you take in a patient with hypertension?
As follows:

• Age: If young, likely to be secondary cause. If elderly, likely to be primary.
• Family history: Family history of hypertension, hyperlipidemia, diabetes mellitus, obesity, etc. may be present in case of primary hypertension. In some secondary hypertension, there may be positive family history, e.g. polycystic kidney disease.
• Past medical history: Previous history of renal disease (hematuria, UTI, renal trauma, pain, pyelonephritis), toxemia of pregnancy (in female).
• Drug history: Prolong use of NSAIDs, steroids, oral contraceptive pill, etc.
• History of smoking.

Symptoms to find out the secondary casue:
a. Symptoms of renal disease like polyuria, frequency, hematuria, loin pain.
b. Paroxysmal attack of headache, palpitation, flushing and sweating (pheochromocytoma).
c. Polyuria, polydipsia, extreme muscular weakness, tingling (Conn’s syndrome).
d. Weight gain, hirsutism, striae, menstrual abnormality in female (Cushing syndrome).
e. Claudication and cramp in lower limbs in a young patient (coarctation of aorta).
f. Frequent attack of headache, vomiting, visual disturbance, neurological features (intracranial tumor).

What physical signs would you look for in a patient with hypertension?
As follows:

• Puffy face: renal failure.
• Central obesity with plethoric moon face, hirsutism, striae: cushing syndrome.
• Pulse: bradycardia suggests raised intracranial pressure, feeble pulse in lower limbs with radiofemoral delay found in coarctation of aorta.
• Blood pressure: high BP in upper limbs, but low in lower limbs suggest coarctation of aorta.
• Anemia: suggests chronic renal failure.
• edema: may be present in renal failure.
• Cardiovascular system: apex may be heaving and shifted (left ventricular hypertrophy or enlargement), murmur may be present in coarctation of aorta.
• Abdomen: bilateral renal mass in polycystic kidney disease, renal bruit in renal artery stenosis.
• Fundoscopy to see retinal change.
• Other finding according to suspicion of cause like intracranial space occupying lesion.
• Bed side urine examination for hematuria and proteinuria.

How to treat hypertension?

As follows:

1. General measures (non-drug treatment of hypertension):

-Salt restriction (< 6 g/day).

-Smoking should be stopped.

-Weight reduction in obese patients (BMI should be < 25 kg/m2).

-Dietary modification: low fat and saturated fat and increase fruits and vegetables, also oily fish.

- Regular exercise (at least 30 minutes dynamic exercise daily).

- Reduction of anxiety and tension.

- Control of diabetes mellitus.

- Restriction of tea and coffee.

- Restriction of alcohol intake (< 21 units/week for men and <14 units/week for women).

- Control of other modifiable risk factors.

2. Drug treatment:

- Diuretic: Thiazide (bendroflumethiazide or cyclopenthiazide).

- ACE inhibitors: Enalapril, lisinopril, ramipril.

- ARB: Losartan, valsartan, irbesartan.

- Calcium channel blocker: Amlodipine, nifedipine, diltiazem, verapamil.

-Beta blocker: Atenolol, metoprolol, bisoprolol.

- Combined alpha and beta blocker: Labetalol, carvedilol.

- Alpha blocker: prazosin, doxazosin.

- Renin inhibitor: aliskiren (this is a newly introduced drug). 215

- Others: Methyldopa (specially for pregnancy).

Treatment of hypertension With Other associated Medical Conditions: 

Hypertension in bronchial asthma:

• Drugs like diuretics, calcium channel blocker, ARB, ACE inhibitor (it may cause cough).
• Avoid b-blockers.

Hypertension in chronic kidney disease: (Target BP is < 130/80 mm Hg).

• ACE inhibitors and ARB may delay progression of kidney disease (if creatinine is >2.5 mmol/l, these should be avoided).
• Calcium channel blocker may be used.
• Thiazide diuretic may be replaced with loop diuretics.

Hypertension in pregnancy:

• Methyldopa or labetalol.
• Other drugs: Calcium channel blocker (nifedipin) may be used. Sometimes, b-blocker may be used but should be avoided in first trimester.
• ACE inhibitor is contraindicated.
• Diuretic is also avoided (there is risk of uteroplacental blood flow reduction).

Hypertension in diabetes mellitus:

• ACE inhibitor, ARB, calcium channel blocker may be used.
• Avoid thiazide (it aggravates diabetes).
• Avoid b-blocker in patient who is on insulin (it masks symptoms of hypoglycemia).

Hypertention in peripheral vascular disease:

• Calcium channel blocker.
• Alpha blocker may be an alternative.
• Avoid b-blocker. ACE inhibitor should be used carefully (as the patient may have renal artery stenosis also).

Hypertension in dyslipidemia:

• Alpha blocker, ACE inhibitor, ARB, calcium channel blocker.
• Avoid b-blocker and diuretic (which worsen lipid profile).

Hypertension in psoriasis:

• Calcium channel blocker.
• Avoid b-blocker, ACE inhibitor (which aggravates).

Hypertension in angina:

• Beta blocker, calcium channel blocker, nitrate.

Hypertension in elderly:

• Thiazide (it is avoided if coexistent diabetes mellitus and gout).
• Calcium channel blocker.